Today’s Date 

Tooth sensitivity to hot/cold or anything elseFood gets caught in between teeth If yes, where  Difficulty chewing If yes, where  Bad breathOther 

Have you ever had orthodontic treatment?   Yes   No

If yes, when? 

Have you ever had periodontal (gum tissue) treatment, such as deep cleanings, root planing, or periodontal surgery?   Yes   No

If yes, when? 

Have you whitened your teeth in the past?   Yes   No

If yes, what method? 

Dental Health History Form

Patient Name: First    Last Name   Nickname 

What are your goals in coming to our practice today? 

What is important to you in a dentist or dental practice? 

What has been your experience with the dentist in the past? 

Date of last radiographs (x-rays) and exam 

Date of last hygiene continuing care appointment (cleaning or periodontal maintenance) 

Former Dentist    Phone 

Address: Street    City    State    Zip 

If you left your previous dentist, what are the reasons? 

Have you had problems with prior dental treatment? 

Are you experiencing any pain now?   Yes   No

If yes, please describe 

Have you ever been pre-medicated for dental treatment?   Yes   No

If yes, why? 

Have you been anxious about having dental treatment?   Yes   No

If yes, would you be comfortable sharing why? 

Would you like to discuss this concern with the doctor to learn about your relaxation options? 

What concerns do you currently have with your oral health or smile? (check all that apply)

Teeth WhiteningOrthodontic treatmentVeneers

Tooth-colored fillingsDental implantsHow to prevent periodontal disease

At-home oral hygiene carePeriodontal treatment during pregnancyOral hygiene care for infants and toddlers

Are you interested in learning more about the following? (check all that apply)

Jaw joint painClenching or grinding of teethDiscolored teethCrowding/Crooked teethMissing teethSpaces in between teethLoose tooth/teethTooth shape or size

Unhappy with appearance of teethOverbiteUnderbiteUncomfortable biteOld fillings (gold or silver)Old crownsSpeech problemsToo much gum tissue when I smile

© 2015 California Dental Association